Robert Graham Center
Presentation to the
American Academy of Family Physicians
11-07-2013
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Triple Aim Initiative: improve quality of care,
increase access, and decrease cost of
healthcare
Primary care: important component in
achieving Triple Aim, challenged to radically
transform care delivery while still facing
archaic traditional fee-for-service
reimbursement
Avenues to achieve care delivery changes
include Blended Payment Models and Care
Management Fees
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American Academy of Family Physicians would
like to provide guidance to their members over
care management fees (CMFs)
Robert Graham Center proposed to first produce
a systematic literature review to begin addressing
the issue:
Estimating/reconfirming the value of a care management
fee within the context of the patient-centered medical
home
 What is the “right” value?
 What should be included?
 What’s the return on investment of a care
management fee to a payer?
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Total 631 identified publications, 63 included
in review
Systematic:
◦ Peer reviewed sources: PubMed, EconLit, JSTOR, etc.
◦ Grey literature sources: CMS, SSRN, etc.
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Snowballing:
◦ Historical: Reference lists of identified articles
◦ Recent: Articles citing identified articles
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Criteria:
◦ Publications since 2009
◦ Language: English
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CMFs are fluid and are set based on a
matrix of three component matrices:
◦ Patient Matrix (age/health)
◦ Covered Services Matrix
◦ Service Intensity Matrix
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PCMH Level determines the practices
location in the Services and Intensity
Matrices
Variability is considerable:
◦ Fees documented in the covered literature
ranged from $0.60 PMPM to $444 PMPM
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Source: McDonald et al. (2007), Peikes, Brown, Chen, & Schore (2008)
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2002; CMS Medicare Coordinated Care
Demonstration; 15 sites; CMFs $80-$444
PMPM
2005; CMS Care Management for High-Cost
Beneficiaries Program; six organizations;
CMFs $100-$295 PMPM
2006; CMS Medical Home Demonstration;
CMFs $17.12-$100.35 PMPM; canceled in
2011in lieu of Multi-payer Advanced Primary
Care Practice Demo
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2011-2014; CMS Multi-Payer Advanced Primary
Care Practice Demo (MPAPCP); eight states; CMFs
from $0.60-$58.50 PMPM, most states had a
CMF of approximately $10 PMPM; Fees
determined based on medical home tier
level/patient disease burden complexity
2012-2016; CMS Comprehensive Primary Care
Initiative (CPCI); seven localities; CMFs average
$20 PMPM, risk adjusted to $8-$40 PMPM for
first 2 years, reduced to $15 PMPM for years 3
and 4
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CMS Initiative Average Care Management Fee Range Comparison
CMS Initiative
Care Management Fee (PMPM)
CPCI
$8-$50
MAPCP
$0.60-$58.50
MH Demo Tier 2
$51.70-$100.35
MH Demo Tier 1
$40.4-$80.25
CMHCB
$100-$295
MCCD
$80- $444
Source: Robert Graham Center compilation
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List of programs:
◦ Colorado Patient-Centered Medical Home Pilot
◦ New Hampshire Citizens Health Initiative MultiStakeholder Medical Home Pilot
◦ Horizon’s Patient-Centered Medical Home
◦ Gundersen Health System
◦ SoonerCare Choice Program
◦ Missouri Health Home Demonstration
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Most determined the CMF by stratifying
payments based on medical home tier
CMFs ranged from $1-$144 PMPM depending on
the program
*
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Care Mangement Fees Vary by Patient Matrix
Program
Pennsylvania
MAPCP
Minnesota
MAPCP
Medical Home
Demonstration
Patient Matrix (Age/Health)
Level 1 (Beneficiary 18 years or younger)
Level 2 (19-64 years)
Level 3 (65-74 years)
Level 4 (>=75 years)
1-3 Chronic Conditions
4-6 Chronic Conditions
7-9 Chronic Conditions
10 or more Chronic Conditions
Tier 1
HCC Score < 1.6
HCC Score > 1.6
Tier 2
HCC Score < 1.6
HCC Score > 1.6
Per Member Per
Month CMF
$0.60
$1.50
$5.00
$7.00
$10.14
$20.27
$40.54
$60.81
$40.40
$27.12
$80.25
$51.70
$35.48
$100.35
Source: Robert Graham Center
Note: HCC = hierarchical condition categories
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Care Mangement Fees Vary by Covered Services Matrix
Program
MCCD:
CenVaNet
MCCD:
CorSolutions
MAPCP:
Maine
MAPCP:
Michigan
Services Covered
In-home monitoring device to monitor patients
RNs and social workers as care managers
Monitor patients over telephone or in-person
Program disease manager and Medicare-certified
home health nurse
Teaching plan w/ eight educational modules
Routine monitoring every other week for first few
months
Covers cardiac/non-cardiac prescription drugs for
low-income patients
Care Coordination Fee
Community Health Team Fee
Care Coordination Fee
Community Health Team Fee
Per Member Per
Month CMF
$80.00
$444.00
$7.00
$2.90
$2.00
$4.50
Source: Robert Graham Center
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Care Mangement Fees Vary by Service Intensity Matrix
Program
CMHCB: Care Level
Management
CMHCB: Texas Tech
University Health
Intensity
Home based care, 24/7 access to
physician, each beneficiary has two
physicians
Uses nurses and care managers for
follow-up visits
16-item tool to assess patient acuity,
such as ER visits in last 6 months,
presence of unmet social/emotional
needs
Remote nurse call-centers to contact
beneficiaries
PMPM
CMF
$295
$117
Source: Robert Graham Center
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RGC’s objective: describe known programs
and their relevant care management fees
Limitations:
◦ No information on negotiation process
◦ Limited details on breakdown of CMFs for most
programs
◦ Without more information cannot determine
‘common’ services
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Technological changes may trump many of
the current systems in the near future(e.g.
tele-health)
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Researchers:
◦ additional research on breakdown of care
management fees and the effect of care
management fees on health care costs – to the
practice, payers, and the ‘system’ as a whole
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AAFP: prescriptive description of either
◦ the ‘ideal’ care management fees covered under
various population/services/intensity bundle or
◦ given a population, the ‘ideal’ services/intensity
bundle covered by care management fees
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For AAFP to offer effective advice to
members:
◦ Attempt to obtain more details on the breakdown of
the care management fees for the CMS programs
reviewed
◦ Investigate primary care practices experience with
negotiating with private payers for care
management fees
◦ Investigate how private payers approach the
negotiation process
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Task
1. Create Program Contact List
2. Ask Programs for final approved CMS
request for funding/proposal
3. Review Proposals
Deadline (tentative)
11/1/2013
(initial contact) 11/8/2013
11/8/2013-11/29/2013
4. Create table breaking down
products/services and patient
population covered by CMF
12/6/2013
5. Create one summary table that
aggregates over individual tables
1/10/2014
6. Write up Report
2/7/2014
Back
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(("care coordination"[Title/Abstract]) OR ("coordinated
care"[Title/Abstract]) OR ("care
management"[Title/Abstract]) OR ("patient
management"[Title/Abstract])) AND (fee[Title/Abstract]
OR fees[Title/Abstract] OR
reimbursement[Title/Abstract] OR
payment[Title/Abstract]) AND (English[Language]) AND
("2009/01/01"[Date - Publication] : "3000"[Date Publication])
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Care Management Through the Decades
1960s
Deinstitutionalization movement for mental health
1970s
National Institute of Mental Health promotes 'case management'
for mentally ill
1980s
State Medicaid programs begin operating primary
care 'case management' programs
1990s
CMS launches national 'case management' payment methodology
Shift toward care coordination
2000s
CMS launches first demonstrations with care management fees
2010s
CMS Innovation Center established, expands payment delivery
change
Source: Robert Graham Center
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